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Based on interview and document review, the facility failed to provide a medical screening exam for 1 (#1) of 26 patients resulting in the potential for less than optimal patient outcomes. Findings include:

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A-2406 Failure to perform a medical screening exam

Based on interview and document review, the facility failed to perform a medical screening examination on for 1 (#1) of 26 patients presenting to the emergency room resulting in the potential for less than optimal patient outcomes. Findings include:

On 10/6/2020 at 0900 during the entrance conference, Quality Coordinator Staff B stated she knew the reason for the EMTALA (Emergency Medical Treatment and Labor Act) investigation and confirmed the name of Patient #1, the patient of concern. She stated the patient had been placed on the emergency department (ED) log; however, no chart had been made.

Review of the ED log dated 2/4/2020-10/3/2020 revealed an entry dated 9/19/2020 at 1641 with a male patient who left because he "didn't want to wait." Staff initials matched Registration Staff F. No medical record was found for Patient #1 at this facility, Facility A, as the patient was not registered or admitted to the ED.

Review of Patient #1's medical record from Facility B, the small acute care hospital receiving facility, revealed Patient #1 was a 40-year old male who presented to the ED via private car on 9/19/2020 at 1701 following an all terrain vehicle (ATV) accident complaining of upper chest, back, and shoulder pain. Computerized tomography (CT-cat scan) results dated 9/19/2020 revealed Patient #1 sustained a 2 millimeter (mm) intracranial (inside the head) bleed, C-6 (cervical spine bone 6-neck fracture) mid spinous process fracture with significant displacement, overriding C-7 spinous process fracture, bilateral clavicle (collar bone) fractures, and a right scapular (shoulder blade) fracture. Additionally, Patient #1 sustained a T-4 (thoracic spine bone 4) and T-6 endplate fractures as well as a T-5 compression fracture. He was listed in serious condition and was transferred via ambulance to a larger acute care facility for neurosurgery.

On 10/6/2020 at 1434, Registration Staff F stated she was not working the night of 9/19/2020 at Facility A, but was at the hospital picking up equipment needed to work off site the following week. Staff F answered the ED lobby door when Patient #1's wife knocked on it and asked if she could help. "She told me her husband had been in an ATV accident and she could not get him out of the car." Staff F stated she went back into the ED and spoke with Registered Nurse (RN) Staff K and was told it would be "a minute" because the ED was full and she would have to find a bed and clean a room. Staff F went out to Patient #1's vehicle and told Patient #1's wife, "It's going to be a couple minutes. They're getting a bed. Please do not remove him from the car" to which the wife responded, "I don't have time for this. I'm going to (Facility B)."

On 10/6/2020 at 1533, RN Staff K stated the afternoon of 9/19/2020 the ED was full with a patient in the overflow room, and two patients waiting in the lobby. "It was a busy night...(Staff F) wanted me to go out and see the patient...At the time, I felt it would be wasting time to go out and look (at Patient #1) too. I was trying to figure the best way to not waste his time and get him into the department..." When queried as to if the ED physician on duty was notified of Patient #1's arrival, Staff K stated he was notified after Patient #1 had already left.

When interviewed on 10/8/2020 at 1516, Trauma Coordinator Staff D stated it was a "failure of good communication between the patient/family and staff...The RN should have done a visual assessment..."

Facility policy #7437006 titled "Emergency Medical Treatment and Active Labor Act (EMTALA), Individual Medical Screening Exams and Transfers" effective 1/2020 states, "A. MSE's (Medical Screening Exams) will be provided to all patients who: 1) Present themselves to the emergency department for treatment..."